CASE REPORT

pISSN 2288-6575 • eISSN 2288-6796

https://doi.org/10.4174/astr.2017.93.1.61
Annals of Surgical Treatment and Research

Rectal perforation by compressed air

Young Jin Park
Department of Surgery, Dongguk University Ilsan Hospital, Goyang, Korea

As the use of compressed air in industrial work has increased, so has the risk of associated pneumatic injury from its im­
pro­per use. However, damage of large intestine caused by compressed air is uncommon. Herein a case of pneumatic
rup­ture of the rectum is described. The patient was admitted to the Emergency Room complaining of abdominal pain and
disten­sion. His colleague triggered a compressed air nozzle over his buttock. On arrival, vital signs were stable but physical
exami­nation revealed peritoneal irritation and marked distension of the abdomen. Computed tomography showed a large
volume of air in the peritoneal cavity and subcutaneous emphysema at the perineum. A rectal perforation was found at
lapar­otomy and the Hartmann procedure was performed.
[Ann Surg Treat Res 2017;93(1):61-63]

Key Words: Intestinal perforation, Rectum, Barotrauma

INTRODUCTION
With the advent of high-pressure compressed air in industrial
work, the risk of associated pneumatic injuries from its
improper use is becoming evident. Among pneumatic injuries,
colon injury by accidental insufflation is one of the most
serious because an enormous amount of air can be delivered
into the rectum in a very short time. It is not well recognized
by the public that the pressure of compressed air can penetrate
barriers such as clothes and the anal sphincter thereby causing
severe colon injury. These injuries usually happen through
careless use, but cases resulting from practical jokes have also
been reported. The author encountered a case of pneumatic
rectal perforation that needed emergency surgical intervention.
CASE REPORT
A 40-year-old male factory worker was admitted to the
emergency room with severe abdominal pain and distension.
Four hours prior, his friend blew out dust from the clothes of
the patient with a compressed air gun (Fig. 1) as was usually
done in his work place. At this time, his friend placed air nozzle
too close to the buttocks of the patient, but the intention of
practical joke was denied according to a witness. Immediately,
the patient experienced severe abdominal pain and gradual
distension of the abdomen. At admission, his blood pressure
was 170/104 mmHg, pulse rate was 133 beats/min, respiratory
rate was 22 breaths/min, and body temperature was 36.8°C.
The patient was pale and clammy. The abdomen was markedly
distended with signs of tenderness and rebound tenderness.
Large amounts of fresh and clotted blood gushed out on digital
rectal examination. On laboratory blood test, white blood cell
count was 6.78 × 103/μL, hemoglobin 16.1 g/dL, while the
other parameters were not clinically significant. Abdominal
X-ray showed large amounts of free peritoneal gas. Computed
tomography of the abdomen and pelvis demonstrated large
amounts of free gas in the peritoneal cavity, retroperitoneal
area, and mediastinum (Fig. 2). Subcutaneous emphysema
was seen in the perineal area and around the scrotum (Fig. 3).
Percutaneous decompression of the tension pneumoperitoneum
was performed by inserting a cannula into the abdomen for
relief of pressure. Sigmoidoscopy was attempted after enema for

Received October 10, 2016, Revised December 8, 2016,
Accepted January 16, 2017
Corresponding Author: Young Jin Park
Department of Surgery, Dongguk University Ilsan Hospital, 27 Dongguk-
ro, Ilsandong-gu, Goyang 10326, Korea
Tel: +82-31-961-7262, Fax: +82-31-910-7977
E-mail: parkyj@dumc.or.kr
Copyright ⓒ 2017, the Korean Surgical Society
cc Annals of Surgical Treatment and Research is an Open Access Journal. All
articles are distributed under the terms of the Creative Commons Attribution Non-
Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which
permits unrestricted non-commercial use, distribution, and reproduction in any
medium, provided the original work is properly cited.

Annals of Surgical Treatment and Research 61

 Annals of Surgical Treatment and Research 2017;93(1):61-63
Fig. 1. Air-gun used in the work place of patient (animal feed
fac­tory).
Fig. 2. Extensive pneumoperitoneum. High intraperitoneal air
pres­sure can impede venous return and induce respiratory di­
stress.
the detection of the perforation site but it did not revealed any
significant findings due to the presence of large amounts of fecal
material and blood clot in the rectum. Emergency exploratory
laparotomy was done under the lithotomy position, which
provides a route for intraoperative colonoscopy when necessary.
The peritoneum was assessed via a low midline incision. On
opening the abdomen, large amounts of air whistled out of
the abdominal cavity. Large amounts of gross fecal material
and bloody ascites were found. A 4- × 4-cm-sized perforation
(Fig. 4), which extended from the retroperitoneal part of
rectum to the rectosigmoid junction, was found. Intraoperative
endoscopic rectal examination after rectal irrigation was done
to evaluate the entire length of the rectum since the presence
of perineal air suggested additional rectal injuries; however,
there was no other damage. Primary repair of the perforation
or anastomosis after bowel resection seemed dangerous under
the circumstance of severe fecal contamination. The damaged
segment of the bowel was resected with closure of the distal
rectal stump and construction of an end sigmoid colostomy
(Hartmann procedure). His follow-up period was completed
62
Fig. 3. Free air in subcutaneous tissue of perineum, distal rec­
tum (arrowhead), and scrotum (arrow).
Fig. 4. Resected segment of bowel shows rectal perforation
with sharp margin.
without any complication and he was discharged 8 days after
operation. Reversal of the colostomy was done after 8 weeks
and the postoperative period was uneventful.
DISCUSSION
Dozens of pneumatic colon injury cases have been reported
since the first report by Stone in 1904 [1]. Case analysis often
reveals unwise behavior. Those cases not involving misbehavior
usually occurred when employees used air hoses to dust off
their clothing as in the present case. It is important to realize
that this injury can occur without inserting the air hose into
the anus. Colorectal injury can occur when the nozzle is merely
placed near the anus, even when clothes are worn [2,3]. It took
only 1 to 2 seconds to deliver enough air to cause major damage.
Andrews, using compressed air to distend the intestine
of a dog, found that normal intestine required a pressure of
0.49–0.88 kg/cm2 to get ruptured [4]. Burt showed that the
average pressure needed to cause a full thickness tear in human
gastrointestinal tracts is 0.29 kg/cm2 [5]. In industrial fields,
 Young Jin Park: Rectal perforation by compressed air

highly compressed air, exerting higher than 10 kg/cm2, is widely
used. It is far greater than the pressure needed for intestinal
perforation. Highly compressed air is known to form a column
that acts like a solid body forcing open the anal sphincter [4].
The funnel shaped anatomy of the buttock facilitates the air
to concentrate around the anus and allows the easy delivery of
air through the anus. Clothes do not protect the force of com­
pressed air as shown by the fact that almost all cases were fully
dressed.
The cecum, having the largest diameter in colon, is the most
susceptible site for iatrogenic barotrauma and is explained by
the law of Laplace where the tension in the wall is proportional
to the radius of the lumen [6]. Meanwhile, most compressed
air related injuries occur in the rectosigmoid region. Pneumatic
injury is relatively rare in the anal canal and distal rectum since
these parts are well supported by external structures and are
anatomically straight. The rectosigmoid region, having many
flexures, is the first part of the colon to be struck by a column
of air. Therefore, most reported injuries occur in the recto­
sigmoid junction, sigmoid colon, and sigmoid-descending junc­
tion [2,3,7]. However, colon perforation can occur in other sites
including the transverse and ascending colon [8,9].
When a lage amount of gas is introduced into the peri­toneal
cavity, respiratory distress occurs due to increased intra­abdo­
minal pressure. The elemination of air using a large bore
needle is a simple and effective method for relieving pneu­mo­
peri­toneum tension and respiratory distress as shown in the
present case.
After recovery from the initial shock, peritonitis due to fecal
contamination should be checked for and treated immediately.
The diagnosis is not difficult if the patient has a history of
abdo­minal pain and distension after exposure to compressed
air. On radiologic examination, a distended colon filled with air
or a large amount of free air in the peritoneal cavity is observed.
Colon perforation itself should be treated according to the
general principles of treatment for colon perforation. For the
perfora­tion of the colon, various types of treatment are possible
from conservative management at colonoscopic damage to
aggressive surgical treatment. Surgical exploration should
garner greater consideration in cases of compressed air induced
colon injury with pneumoperitoneum since it accompanies
fecal contamination, and preoperative evaluation of the extent
of damage is difficult. Conservative managemet would also be
possible in mild cases of peritonitis. At the time of laparotomy,
primary repair, segmental resection, with or without colostomy,
can be performed depending on the extend of contamination.
Primary repair or anastomosis after resection was not appro­
priate for the present case as the fecal contamination was
severe and the bowel was edematous. It should be remembered
that a second operation might be necessary in cases of delayed
colon perforation [9]. The prognosis has generally been favorable
in recent years, although early collective reviews reported grave
results [10].
The careless use of compressed air results in catastrophic
results as shown in this case. Therefore, workers handling
compressed air should be made aware of the hazards before
allowing them access. The potential dangers should be pro­mi­
nently displayed in writing in places where it is being used to
minimize such accidents in the future.
CONFLICTS OF INTEREST
No potential conflict of interest relevant to this article was
reported.

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